How the Health Equity Funds System helps Cambodia's poorest citizens

In Cambodia, extreme poverty includes those who are reasonably certain of their food supply for a single day, and those who are not. A family might have only a single meal all day. Imagine, then, the terrible burden that any expense—let alone a large medical bill—would impose upon such a family.

Social health in Cambodia

Cambodia has made significant progress on a range of health indicators over the past decade and has demonstrated a strong commitment to pro-poor health policies, most notably with the development and expansion of the Health Equity Fund System (HEF), which is the largest component of the overall social health protection strategy outlined in Cambodia's draft Health Financing Policy. University Research Co., LLC (URC) has been integral to the development this initiative over the past 10 years, through programs like the Better Health Services Project (BHS) and its follow-on in 2014, the Social Health Protection Project (SHP).

URC and partners Buddhism for Health, Partnership for Better Health, the Open Institute, and the Nossal Institute of Global Health at the University of Melbourne are working to strengthen the Royal Government of Cambodia's capacity to continue progress toward universal health coverage. Svay Phalla and his family are just one example of the positive effect SHP Project and the Health Equity Fund System are having on the lives of the poorest citizens of Cambodia.

Free health services for Cambodia's poorest citizens

Today, Svay Phalla lives in a rented house with his five dependent children in a stable neighborhood in Chong Prek village. Before his family received their HEF card, family illness or medical needs could send the family hundreds of thousands of Riel in debt—in fact, Mr. Svay's landlord had helped pay for medical expenses in the past. The father's finances are by no means secure: if the construction company where he is a day laborer actually hires him to work six days a week, he can make around US$118.00 per month, but spends US$55.00 on rent and utilities and another US$44.00 on food. In Mr. Svay's family, there is no room for other expenses.

Earlier in 2014, Mr. Svay's wife was gravely ill and pregnant with their youngest child. Her condition was serious enough that she was referred from the health center to Mean Chey Referral Hospital. There, she was diagnosed with hypertension, fluid on the lungs, and cardiopathy, and her condition was worsening. As a result, she was referred to the Khmer-Soviet National Friendship Hospital, where she was admitted to the obstetrics ward. Noting her deteriorating condition, the doctor there decided to perform an emergency cesarean section and the baby's life was saved. Mr. Svay's wife succumbed to her illness the next day. Without the HEF, this newly widowed father would have been destroyed, financially; instead, the fund covered the entire cost of her hospitalization (1,233,000 Riel,* or US$303.00).

The family's HEF card is contributing to the family's improved circumstances. ". . . [M]y family's living conditions are better because I hold the HEF card," Mr. Svay explained. "When my family members or I get sick, I can use the card for free treatment at Prek Eng Health Center, which is located not far away from my house, and Mean Chey Referral Hospital." The free treatment his family receives, he said, "reduces a significant part" of his family expenses. His family is healthier, and he plans to send his children to school.

* All calculations are based on currency rates from December 2014. US$1 = 4,059 Riel

Cambodian Health Context

Cambodia is a predominantly rural country, with only 20% of its population of 14.9 million (2013) classified as urban. While Gross Domestic Product per capita has risen considerably over the past decade to $946, this figure does not reflect large variations across the country or the fact that the majority subsists on rural farming rather than formal employment. Cambodia has seen considerable socioeconomic improvement over the past 15 years, due to increased wealth, improved infrastructure and a series of interventions initiated by the Ministry of Health with support from its health partners. This is reflected in the fact that Cambodia has made impressive gains in many areas of health since 2000. Under-five mortality has declined from 125 to 54 per 1,000 live births (all comparisons unless otherwise stated are between the 2000 and 2010 Cambodian Demographic and Health Survey), under-one mortality from 95 to 45 and child mortality from 33 to 9. The maternal mortality ratio has declined from 432 to 206 per 100,000 live births, antenatal care has risen from 38% to 89% of pregnant women, and delivery with a skilled birth attendant has risen from 32% to 71%.

USAID and URC support has been critical to many of the reforms to the Cambodian health system during the last decade; that support has provided technical assistance in the areas of quality improvement, health informatics, health financing and social health protection.

HEFs were initiated by NGOs in the early 2000s in reaction to the introduction of user fees at referral hospitals. URC, with USAID support, has helped, since 2003, to develop HEFs into a robust national social health protection system that is a uniquely Cambodian and now covers about 3 million identified poor. Benefits provided by HEFs include the payment of user fees at public health centers and hospitals, travel reimbursements and caretaker food expenses for inpatient care. Third-party and implementer evaluations have shown that HEFs reduce the burden of debt for health care, increase utilization by the poor and appear to work in synergy with other MOH health financing and quality improvement strategies.

Svay Phalla and his family have a measure of financial security, thanks to the HEF. Image courtesy of The Social Health Protection Project, Cambodia